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SANITARY PERMIT APPLICATION C UNTY <br /> pItHR <br /> _ In accord with ILHR 83.05,Wis. Adm. Code BURNETT <br /> S ATE SANITARY PERMI # <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than S ATE PLAN I.D.NUMBE <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> SW '/4 SW '/4, S 24 T 40 , N, R 1.4 jtlV f W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS ON NAME <br /> 4969 ZEALAND AVE NO. 11&12 NA FEN PARK <br /> CITY STATE ZIP CODEPLAG <br /> HONE NUMBER CITY NEAREST AQ, NDMARK <br /> NEW HOPE, MN 55428 ❑ VILE : SCOTT MC AI,�A <br /> It. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1 Check#2,3 or 4,if applicable) <br /> 1. a. ® New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of E.❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreem aritto County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ®Conventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. My6ee a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W kTER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 43 410 1410 94.9 Feet ®I rivate ❑Joint El Public <br /> VI. TANK CAPACITY #of Prefab. Site Fiber- App- <br /> in allons Total Manufacturer's Name Con- Ste I Plasticr. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 0 0 1 WIESER'S ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ ❑ I ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: B smass Phone Number: <br /> ARLYN J. HELM 9 _ 3360 15 635 7595 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P.O. BOX 71, SPOONER, WI 54801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> SAME 3331 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num er: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved itary Permit Fee Groundwater ate Issuing Agent S gnature(No Stamps) <br /> Approved ❑ Owner Given Initial �-3/"n ,(1L Surcharge Fee I ) r <br /> Adverse Determination ko I V -moi j•(a(� '7 j�' -,�.i_ > b� ��((;Lo li <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DIS?RIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbe <br />